Annual Oration 1970
By Dana L. Farnsworth, M.D.
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us.... Charles Dickens, A Tale of Two Cities
At the beginning of the 60's, the prospects for a period of social, economic and political stability in the United States looked very promising, at least from our present vantage point. The cold war was thawing, depressions (or recessions) and inflation were not particularly threatening, the war on poverty was in progress, and hopes were high that the problems of civil rights were to be solved. Colleges and universities were pursuing their various tasks quietly and yet with sufficient attractiveness that students were clamoring to get into them, even as they are now.
Now, 10 years later, the emotional state of our people has undergone a change so dramatic as to be almost unbelievable. The young particularly appear to have lost confidence in their elders, in their government and in the chief institutions of society, — the church, the courts, the colleges and the universities, — and many of them have lost hope for the future and pride in themselves. I can recall no period in recent years — that is, since 1900 — in which so many young people were willing, even eager, to condemn their elders while at the same time an increasing number of people of all ages were inclined to believe the worst of one another.
Those who are involved in the various forms of youth protest come from many backgrounds. Most of them are of middle-class origin, from homes with a predominantly liberal orientation, and have usually been brought up in comparatively affluent circumstances. Another large group is that of the black students, many of whom have come from urban areas with a high incidence of poverty and family instability. These groups share a common concern over the faulty distribution of material goods and services, some because they have too little and others because they have too much — and feel guilty about it. Some of the young have become so critical that they have moved beyond the usual forms of protest and have become alienated from society and lost much of their commitment to academic values and intellectual achievement. Psychologic disturbances are common among them.
During the years in which the present college and university students were in secondary school, the gap between the generations became symbolized by marked changes in speech, conduct, dress and manners. These reflect the unprecedented speed and magnitude of all forms of social change, dwarfing anything that has occurred in the past. Not only are such changes frequent, but their rate is continuously increasing. Communication through the mass media is now theoretically all-pervasive; but in response to economic pressure, it has tended to distort reality by overemphasizing the abnormal, the violent and the destructive aspects of human behavior to the neglect of the myriad phenomena that add meaning, quality, dignity, and security to life.
To add to the urgency of recurrent crises, our governments have devised far more effective means of destroying human life and property in the name of defense than they have programs for safeguarding them. Positive forces, such as working for improved economic status, higher health standards or meaningful training of youth to assume the duties of maturity, are constantly limited by the negative forces of greed, hostility, intolerance and lack of consideration by the powerful of the total range of needs of all persons. Complex technology, IBM-card bureaucracy and a sense of personal impotence prevail; the man-made is an anachronism or a luxury. Above all looms the threat of nuclear disaster, of total annihilation triggered by accident or unpredictable and unpreventable events. This threat may well be more demoralizing to individuals than a destructive "conventional" war that galvanizes an entire nation into a co-operative defense.
Many of our people, young and old, are angry, confused, dismayed and justifiably alarmed. Young people from the middle and upper classes are angry because their contemporaries in the lower classes do not have the economic, social, educational and cultural advantages that they have had. The latter are angry because they have come to realize that they lack these advantages. Failure to carry out the ambitious programs designed to give civil rights to everyone and to minimize or eliminate poverty has had a shattering effect. Environmental pollution, caused by technologic progress that does not concern itself with all its side-effects, demonstrates a potentially fatal lack of understanding concerning man's psychologic and biologic needs. The issues raised by the Vietnam war have colored and exaggerated all the other sources of frustration. But most of all, our young idealists have become disillusioned because of the discrepancy between the American Dream and what they see in public and private life. They are in revolt, not against our values, but because we do not uphold nor practice them.
The more permissive modes of childrearing that have become current since World War II have created in young people a demand for immediate gratification of desires and attainment of goals. But permissiveness alone is not the culprit; Masterson has commented that permissiveness, when accompanied by inconsistency and occasional punitive attitudes, is a guaranteed prescription for trouble. As children, our present generation of young people were taught to be both idealistic and critical; but they were also less disciplined, especially in regard to sustained, united action and in the balancing of all the rights and values involved in a particular situation. They embarked upon plans to improve society, grant civil rights, reduce poverty, but encountered unforeseen resistances. The glaring discrepancy between the ideals they had been taught and the ethical practices they observed in "respectable persons" became more apparent. But their lack of discipline and unwillingness or inability to sustain action mean that when they encounter opposition, they have no constructive technics for dealing with it, and they react with fear, anger and violence.
This tendency to protest and extremism is in part a product of affluence, simply because young people have the time and energy for it. They are not constantly involved in making a living or coping with external dangers. But this in no way means that their concerns are unimportant or invalid; on the contrary, they must be considered seriously and with respect. They are real, disturbing and sometimes overwhelming, and although one may wish that the young dealt with them differently, they cannot be dismissed as meaningless.
Although most of the publicity concerning the unrest of young people has centered around college students, unrest is by no means confined to them. There is a solid consensus that every class entering college and graduate school contains a higher proportion of persons whose behavior and attitudes have been so conditioned that they are critical of their new environment, often before they know its characteristics. Even those who come with negative attitudes toward student unrest soon find themselves affected by strong peer-group pressures pushing them toward dissent.
Most entering college students wish to pursue their studies without interruption, but the forces that tend to radicalize them are strong and pervasive. Their conservative leanings are strengthened by their own desires to fit themselves for careers, the influence of their parents when family relationships have been satisfying, and their impatience with destructive forms of protest observed in their peers. Their radical tendencies are increased when college experiences seem to them illogical or irrelevant, faculty contacts are few or unsatisfactory, family relationships are impaired, and national and local events suggest repressive policies and technics toward the underprivileged and the young. So many influences are brought to bear on them that it is impossible to predict with certainty in any particular institution what the ultimate direction of their actions will be. But Dean Franklin Ford, of Harvard University, expressed his confidence in their ultimate good judgment:
...I believe our students will ultimately prove to be not only an innovating, but also a steadying, force. There are already heartening indications that the great bulk of the student body will not be content to spend their time at Harvard in conditions of emotional smog and intellectual squalor.
Young people are still eager to gain entrance to institutions of higher learning; yet when many of them do gain admission they immediately begin trying to change the entire structure, function, methods of procedure and even the goals of the college they are attending. The university is probably less at fault in causing and sustaining social problems than almost any other large social institution, but it is the main structural focus of the lives of these protesting young people and a ready target for their misdirected energies. They see it as a microcosm of the world at large, and demand changes both in the university's internal operation and in its relations with the rest of the community. They want the university to take the lead in effecting change rather than to rely on training persons who will exert leadership in social reform.
What is most frustrating to a young person who is well informed, idealistic, ambitious and disturbed at the discrepancy between what he sees and what he believes to be possible is that he feels so powerless to effect change. No one person is able to make a commanding difference in the behavior of many persons. Yet when a few persons, even a few thousands, band together for a common purpose, their frequently overemphatic behavior produces counteractions on the part of those they are trying to influence that result in a negation of the efforts of the reformers. Thus frustration becomes exacerbated, often leading to hostility, despair, resignation or the development of revolutionary attitudes.
What are the protestors most concerned about? Their specific demands in any given situation can be seen as a response to the basic belief that human needs must not be subordinated to technologic advances or corporate profits. They fear an increased tendency toward subordination of the individual to the power structures, regimentation and lack of privacy, destruction of the environment and the spiraling increase of nonessential and quickly obsolete consumer goods to amuse the affluent while the poor are more and more neglected. Some of the specific issues are so divisive that they merit special consideration in any discussion of what is happening in medicine. These include the Vietnam War, the problems centering around the attempts to eliminate all aspects of racism, the misuse and abuse of drugs and our misplaced priorities, both those of society at large and those of medicine in particular. To some degree, the resolution of each of these issues depends on progress in resolving the others. Not only does this call for profound change in social and governmental policy, but even more importantly, it requires revolutionary changes in personal attitudes and opinions of many people.
Robert Frost once said that a central problem of many of the underdeveloped countries of the world was that they were trying to get ahead before they got caught up. In some ways this is the dilemma of many of our younger colleagues in medicine. They see the vast unmet needs in great numbers of our people for the most simple and elementary forms of medical treatment. They observe the most advanced and sophisticated forms of applied technology being used in our hospitals to keep people alive or to correct defects formerly considered irremediable, and they also note, within a few hundred yards, grinding poverty, ignorance, hopelessness and anger among people caught in a trap not of their own making. They see physicians ignoring the health of the public, limiting their view to the health of their own patients. As medical students get into the clinics and the hospitals, working with large numbers of people suffering from overwhelming personal problems about which they can do relatively little, their own feelings of powerlessness are frequently displaced into dissatisfaction and even anger about "the system." "Something ought to be done about it."
There ought, they feel, to be more income for everybody, more equitable distribution of goods, more efforts at preventing disease, better housing, better schools, better teachers, more consideration of the human needs of people — and on and on. And they are right. Unfortunately, many students are insufficiently aware of how long and difficult has been the course that brought us to where we are, and how complex and demanding are the efforts needed for change.
In a simpler era, when medicine was largely palliative rather than curative, whatever medical care was available could be shared by most people —there wasn't too much of it, but what there was could be spread with comparative ease. Now, with complex modern equipment and teams of technologists at the disposal of the physician, the logistics of giving the best that medicine has to offer to anyone who needs it are staggering. If all who need complex medical procedures and care cannot get them, who should be the favored ones, and why? Thus, medicine (including the basic sciences responsible for its accomplishment) becomes embroiled in ethical controversy and to some extent a victim of its own successes.
Funkenstein divides the development of medicine in this century into four eras, depending upon the predominant emphases in practice, teaching and social responsibility. The general-practice era, from 1910 to 1940, emphasized the needs of the individual patient and how physicians could adapt methods from the basic sciences and apply them as effectively as possible to all patients who came for help. From 1940 to 1959 the role of the specialist became increasingly important, and the general practitioner had more and more difficulty in maintaining his scope of activities. During the next decade science and research grew in favor, with so much intense activity being focused on extremely specialized laboratory procedures that clinical skills often appeared to be taking an inferior role. The prestige of the laboratory scientist waxed whereas that of the clinician who ministered to the patient waned. The fourth era is just beginning, in which many of our younger colleagues particularly, and large numbers of medical students, are thinking strongly in terms of the need for achieving a more even distribution of medical care than has heretofore been accomplished. This involves changes in methods of financing, a change in emphasis from research to delivery of health care, and a great increase in concern for the social and cultural factors that interfere with health.
The students who are taking the lead in formulating social policy for medicine assume that our social system can be changed if enough people desire change. They view themselves as working at the interface between society and the individual. They take seriously the admonitions, acquired from dominant influences in their backgrounds, that all people should have good medical care. When they see this ideal being massively disregarded they quite understandably become concerned and in many instances indignant. The formation of the Student Health Organizations and a rapid shift in activities and attitudes of members of the Student American Medical Association have resulted.
Research funds for medical schools are currently being drastically reduced, as a part of an overall program to slow inflationary tendencies. This may deflect more young physicians into clinical practice. Yet at the same time this development, desirable from the social and economic points of view, may delay the advance of the basic sciences essential to progress in medical treatment. Spreading the distribution of medical care more equitably need not and should not be accomplished at the expense of impairing the medical research of the future.
Many young people who are quite well informed about the way society maintains itself in the technical sense are not sufficiently aware of how complex and yet fragile are the bonds that hold organizations together. Just as a family achieves and maintains stability because of the character and emotional strength of the parents and the love and respect they give and receive from their children, so an organization or a community perpetuates and strengthens itself by the mutual respect with which the key individuals in it regard one another.
A democratic society is an open society, and the maintenance of the web of morality that holds it together depends upon support by a consensus of the individuals who comprise it. People unite behind a competent, compassionate, energetic, likable leader. Conversely, they lose this cohesion when their leaders are abrasive, fault-finding, irresponsible and self-centered.
In the medical profession the balance may have been swung too far toward a consideration of the individual in acute distress and away from concentration on the agents or social conditions that undermine health and a state of well-being. The sick person is visible, his plight excites compassion, and this emotion results in efforts to relieve him. Extended beyond the treatment of the individual, it encourages the development of even more intricate and brilliantly conceived means of prolonging life. Organ transplants, kidney dialyses, intensive-care units for patients with coronary occlusion, and all the array of technologic applications to prolong life have made modern medicine an exciting and immediately rewarding field both for physicians and for their patients.
But here the paradox appears. What the few have benefited from, the many desire. Medicine has advanced on the technical frontiers so far and so fast that its successes with individuals have endangered its basic stability. It has gone beyond the reach of its supply lines, so to speak. The people want "high-grade medical care," and only a few can get it. Those who live in rural areas and in the urban ghetto, those who do not have financial resources, cannot get what the well-to-do in urban centers can get. But even if all our people did have the means to pay for good medical care all of them could not receive it. In the first place, there are simply not enough physicians and other health workers to care for everyone ideally; secondly, many of our people do not know enough about proper health care to know how to want it. The Head Start programs have shown that millions of youngsters have no appreciation of what going to a dentist or doctor means. Berating the medical profession and the medical schools for not providing proper care is only to delay its ultimate development. Our only constructive course is to assume a posture of real examination of the problems and their solutions.
In line with a current tendency to find some vast conspiracy on which to fasten blame for all short-comings of the past (as, for example, the "military-industrial complex"), one medical student sees the large complex medical centers and teaching hospitals as the culprit, and describes them as "strikingly unresponsive to the need for sweeping changes" as well as "private, elitist, and unaccountable to anyone except financial interests and their own technocratic leadership." That there are problems within medicine in the United States is of course true; any large and complex system has deficiencies and areas in which its vision is less than perfect. But the impatient critics fail to see that were it not for the co-operation of the university and the hospitals and the industries that work with them, medicine as we know it would scarcely exist.
Many medical students see little connection between what they are doing and the ideals they hold regarding improvement of the quality of living in their communities. This condition exists in the presence of serious shortages in the supply of health professionals in practically all fields. If it were possible to make conditions in the various auxiliary health professions more attractive as a life career, many urgent problems (discontent and frustration of the young and the unmet health needs of vast numbers of our own people) could be ameliorated. This requires a change in our attitudes toward the traditional hierarchy in medicine, to encourage more young people to go into the auxiliary health fields. If they and their future colleagues in health programs, the medical students, could have better integration of their training programs and better relations, such integrations, it is to be hoped, would produce understanding and respect for one another's functions in a health team.
If the standards of health care in this country are to be raised (or even maintained and extended to those not now receiving adequate care), many more skilled persons must be trained to aid physicians and nurses in their treatment of patients and in the development of preventive medicine. The need for such skilled workers is universally conceded, and the huge numbers of young people eager for relevance and beneficial change could fill it. The obstacles lie in the resistance to change — in inflexible training programs, inadequate opportunity for both vertical and lateral mobility in the auxiliary health professions and occupations, rigid and archaic licensing regulations in the various states, and insufficient financial incentives for many with high ability but without full formal medical training.
Numerous programs are now being developed to train physicians' assistants (by whatever name they may be called), but the nature of their training and how their services can best be used remain to be determined. Members of the medical profession have the double duty of encouraging such attempts in all reasonable ways and exercising such supervision as will ensure no decrease in the quality of health care when developed by teams of health workers rather than by individual practitioners.
Medical students are particularly critical of the emphasis in the preclinical sciences on mastering each particular one as a science rather than as an aid to learning the facts that will help them become competent clinicians. They decry the overstrong influence of departments at the expense of the total teaching program. Their criticisms of teaching methods are devastating. They want more members of minority groups admitted to medical schools. They want more effective health-care programs designed to care for the needs of citizens (particularly the poor) in the communities where medical schools are located. They want more of their time to be available for elective rather than required courses or activities.
In short, they frequently expect more of the medical school than it can give, partly because of inadequate resources and partly because its faculty members have difficulty in making changes until there is some indication that new methods and procedures are likely to be more effective than the old. The major barrier to change is the threat posed to the individual by the uncertainties engendered and the shifts of power.
The tendency toward polarization of older against younger and conservative against radical can be particularly damaging when self-destructive actions are used as symbols in the struggle. A serious problem for medicine seems to be developing because of the widespread use of drugs (both legal and illegal) for nonmedical purposes. An attitude of acceptance of such use has become one of the weapons in the cold war between generations, and we in the medical profession have a peculiarly sensitive problem in the form of a growing tolerance and acceptance of such drug use by medical students. Although many persons may use marihuana at occasional intervals without evidence of physical harm and with no apparent unfavorable results, it remains to be seen whether its use by physicians can be tolerated, especially when the effects of the drug on judgment are considered. As I have said elsewhere, members of the medical profession have a peculiarly important role in the development of effective programs for the control of drug abuse. Use of drugs among medical students as a form of generational protest not only may blunt their feeling of responsibility for developing such programs, but may lead to a casual attitude concerning personal drug use that will increase the already-present occupational danger of drug addiction.
From my somewhat limited observations, it appears that the proportion of students clamoring for drastic changes in the medical schools and in systems of delivering health care is greater in each incoming class. This impetus for change is admirable in many ways; yet if the forces for change result in lowering the standards of medical care in the effort to achieve wider distribution, neither patients nor members of the health professions will benefit, and the medical profession, both its conservative and its radical branches, will be blamed.
The cynicism of many of our younger colleagues in medicine is pervasive — directed toward their teachers or older colleagues, the researchers in the laboratory, the narrow emphasis (in their view) on helping the sick patient, and all those who have not made medical care available to everyone all at once. As Tillich commented,
. . . There is scarcely one thing about which we may not be cynical. But we can not be cynical about the shaking of the foundations of everything... We can be cynical about the end only so long as we feel safety in the place in which our cynicism can be exercised.
He goes on to say that if the foundations of this place (for us, medicine) and all places (society as a whole) begin to crumble, cynicism itself crumbles with them. Only two alternatives then remain, faith and despair. For us, faith means a reaffirmation of our belief that the science and art of medicine have a major contribution to make to the welfare of everyone and that we must not and cannot let our differences obscure the vast expanses of our profession about which all of us are in complete agreement.
Our task as physicians who are as interested in the trends of modern society as we are in the promotion of the medical profession is to find a way of directing the vast discontent of young people, and particularly of those who are going into the health professions, into channels that will not only result in making good health care available to all our people but also give the participants a sense of accomplishment while doing so. As at any time of rapid social change, great care must be taken to avoid differences in goals and technics bringing about so much rancor that co-operation toward achieving the common ideals becomes difficult or impossible. Intense polarization of opinion through demonstrations and confrontations has become fashionable, even commonplace. Accusations and counteraccusations are common. But as Professor Paul Freund has said, "The trouble in fighting hypocrisies is that righteousness about ends soon becomes self-righteousness about means." In medical education, in the schools and colleges, as in life, reason and civility are still basic attributes.
In the welter of dissatisfactions with the current state of health-care delivery systems, some of the main goals for improvement are beginning to emerge clearly. There is a consensus that both excellence and equity of medical and preventive services are imperative. There should not be several classes of health care, but one system available to everyone that has provisions for appropriate modifications for those with quite special needs or desires. Fragmentation of health care through emphasis on many specialty clinics not co-ordinated with one another must be eliminated or minimized. Medical treatment must be made available universally, preventive medicine should be on a par with curative medicine, and the social, cultural, educational and economic factors impeding the attainment of medical care must be as much a concern of health professionals as the more technical advances. And, finally, the various forms of activism whose goal is the attainment of these reforms must not be pursued in such a manner as to produce polarization of the issues, hostility among the various groups, or the general anarchy that occurs when emphasis on who is right prevails over concern for what is right.
When all the analyses of the causes of youthful unrest and the means by which the discontent is expressed are examined, the basic causes as well as the remedies become increasingly clear. We have given too little attention to the task of aiding and strengthening the family in its efforts to bring up children with a sense of responsibility as well as curiosity, respect for themselves and others, and a willingness to work co-operatively with others in efforts to develop a kind of life that produces a sense of fulfillment. If all of us in medicine and the auxiliary health professions can see that we are in a period of crisis concerning values and can learn to work together, to co-operate with persons from other disciplines to minimize or eliminate poverty, and to change our priorities to include all the things that give dignity and meaning to human life, we can transform discontent and protest into one of the most invigorating periods in medical history.
A blueprint for such co-operative effort is already available in the recently published report of the Joint Commission on Mental Health of Children. In this document, the result of the deliberation of several hundred persons concerned with the development of children and youth, the causes and remedies of many of our present dilemmas are clearly stated. The entire medical profession, not just those working primarily with children, has an unrivaled opportunity to get behind the most important of all human endeavors — the care, nurture and training of all our young.
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Farnsworth, Dana L. "Youth in Protest." New England Journal of Medicine 282, no. 22 (1970): 1235-40.
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